Sepsis Webinar Series

2018

Presenter:

Angela Craig, APN, MS, CCNS

Please dial your Audio PIN#

which you can find under the Audio tab

• Consultant Angela Craig, APN, MS, CCNS

• For THA HIIN hospitals

• Conducted on site at your hospital

• Tailored to meet your unique interests and

needs

Sepsis Consultation Services

“Our thanks to Angela Craig and THA for this opportunity! We can’t

say enough good things to express how pleasant and encouraging her

visit was. I trust that more hospitals will utilize her expertise services

and look for better opportunities to care for patients with Sepsis!

Thank you very much!

• Save the Date - May 9, 2018

• In partnership with Qsource

– Will include nursing homes, home health

agencies, and other post-acute providers

Sepsis Readmissions Workshop

• 8 webinars: 4 instructional, 4 coaching/sharing 1. Organizational Consensus that Sepsis Be Managed Early and

Aggressively

2. Early Screening with Tools and Triggers

3. Implementation of the Sepsis Bundles

4. Measuring Success

• Instructional webinars are recorded and posted,

along with handout materials, on the Tennessee

Center for Patient Safety website:

www.tnpatientsafety.com/initiatives/sepsis

Sepsis Webinar Series

Touch Point

A N G E L A C R A I G A P N , M S , C C N S

I C U C C N S & S E P S I S F A C I L I T A T O R A T C R M C

SEPSIS PROGRAM DEVELOPMENT TIER II

Angela’s Contact Information:

acraig@crmchealth.org 931-239-4904 (cell)

Infection Prevention

VAE (VAP) Bundle BSI

Organizational Consensus that Severe Sepsis

Must be Managed Early and Aggressively

Early Screening with Tools and

Triggers

Implementation of

the Sepsis Bundles

Measuring

Success

CQI1

SECOND TIER: IMPLEMENTATION OF SCREENING TOOLS AND

TRIGGERS

7

CAUTI

Hand Washing

Documentation Improvement

~ Accurate Coding 1Continuous Quality Improvement

Adapted from: Sepsis Solutions International

SCREENING FOR SEPSIS AND PERFORMANCE IMPROVEMENT

1. Performance improvement efforts in severe sepsis

should be employed to improve patient outcomes

(1C).

Dellinger, 2013 CCM

SEVERE SEPSIS: DEFINING A DISEASE CONTINUUM

Systemic Manifestations of

infection

with a

presumed or confirmed infectious process

Sepsis Systemic

Manifestations of infection

Known/Suspected Infection

Severe Sepsis

Sepsis with 1 sign of organ

dysfunction, hypoperfusion or hypotension.

Examples: • Cardiovascular

(refractory hypotension) • Renal • Respiratory • Hepatic • Hematologic • Unexplained metabolic acidosis

Adult Criteria

A clinical response arising from a

nonspecific insult, including ≥ 2

of the following:

Temperature:> 38°C or < 36°C

Heart Rate: > 90 beats/min

Respiration: > 20/min

WBC count: > 12,000/mm3,

or < 4,000/mm3,

or > 10% immature

neutrophils

Altered mental status

BG >140 (non diabetic)

SIRS = Systemic Inflammatory Response Syndrome Bone et al. Chest.1992;101:1644-1654.

Shock

DEFINITIONS

• Sepsis: presence of infection (suspected or

confirmed) with systemic manifestations of infection

• Severe Sepsis: Sepsis-induced tissue hypoperfusion

or organ dysfunction

• Septic Shock: Hypotension that persists despite

adequate fluid resuscitation

SERUM LACTATE IS ASSOCIATED WITH MORTALITY IN SEVERE SEPSIS INDEPENDENT OF ORGAN

FAILURE AND SHOCK MIKKELSEN, MARK ET AL CCM 2009 VOL 37 NO 5

Objective:

• Test whether the association between initial serum lactate level and mortality in patients presenting to the

ED with severe sepsis is independent of organ

dysfunction and shock

Design:

• Retrospective, single center cohort study

• Academic teaching hospital

Patients:

• 830 adults admitted with severe sepsis in the ED

• Stratified lactate into 3 groups: low (<2), intermediate (2-

3.9) and high (> or equal to 4)

SERUM LACTATE IS ASSOCIATED WITH MORTALITY IN SEVERE SEPSIS INDEPENDENT OF ORGAN

FAILURE AND SHOCK MIKKELSEN, MARK ET AL CCM 2009 VOL 37 NO 5

Results: • Intermediate and high

serum lactate significantly

associated with mortality

regardless of the presence of

shock or other organ

dysfunction

•A single serum lactate seems

to risk-stratify patients

independent of organ

dysfunction or hemodynamic

instability

CAN WE PREDICT MORTALITY IN INFECTED PATIENTS?

Systolic BP ≥ 90 still have ↑ lactate and mortality

ICM 2007 Vol 33: 1892-1899

Lowest ED

reading

Predicting Mortality in Infected Patients

HOMEOSTASIS IS UNBALANCED IN SEVERE SEPSIS

Carvalho AC, Freeman NJ. J Crit Illness. 1994;9:51-75; Kidokoro A et al. Shock. 1996;5:223-8; Vervloet MG et al. Semin Thromb Hemost. 1998;24:33-44.

Coagulation

Inflammation

Fibrinolysis

INFLAMMATION, COAGULATION AND IMPAIRED FIBRINOLYSIS IN SEVERE SEPSIS

Reprinted with permission from the National Initiative in Sepsis Education (NISE).

Endothelium

Neutrophil

Monocyte

IL-6 IL-1 TNF-

IL-6

Inflammatory Response to Infection

Thrombotic Response to Infection

Fibrinolytic Response to Infection

TAFI

PAI-1

Suppressed fibrinolysis

Factor VIIIa Tissue Factor

COAGULATION CASCADE

Factor Va

THROMBIN

Fibrin

Fibrin clot Tissue Factor

MICROCIRCULATION OF SEPTIC PATIENT: OTHOGONAL POLARIZATION SPECTRAL IMAGING

• BP: 120/80

SaO2: 98%

1. www.opsimaging.net. Accessed April 2004. 2. Spronk PE, Ince C, Gardien MJ, et al. Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet. 2002; 360:1395-1396.

MICROCIRCULATION OF SEPTIC SHOCK PATIENT: OTHOGONAL POLARIZATION SPECTRAL IMAGING

• Resuscitated with

• fluids and dopamine

• HR: 82 BPM

• BP: 90/35 mm Hg

• SaO2: 98%

• CVP: 25 mm Hg

1. www.opsimaging.net. Accessed April 2004. 2. Spronk PE, Ince C, Gardien MJ, et al. Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet. 2002; 360:1395-1396.

WHY DO YOU NEED TO HAVE A SCREENING PROCESS?

• TIME IS TISSUE!!

• Similar to trauma, AMI, or stroke, the speed and

appropriateness of therapy administered in the initial

hours after severe sepsis develops are likely to

influence outcomes.1

• To screen effectively, it must be part of the nurses’ daily routines— i.e., part of admission and shift assessment

• Must define a process for what to do with the results of the screen

If you don’t screen you will miss patients

that may have benefited from the interventions 1. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296-327.

Positive Screen

for Severe

Sepsis?

SCREENING FOR SEVERE SEPSIS

Yes

No

Surviving

Sepsis

Guidelines Monitor frequently

whether on

the ward

or ICU

Standard care

PAPER OR ELECTRONIC….THAT IS THE QUESTION

20

Method Pros Limitations

Paper form • Nurses critically think as they screen the patient

• Easy and quick to develop • No cost

• Screening is intermittent • Paper can be misplaced • Static—no ability to automate

an alert

EMR form • Nurses critically thinks as they screen the patient

• Can automate alerts for positive screens

• Screening is intermittent • Length of programming time • Cost

EMR—real time, continual screening

• 24 hour screening • Can automate alerts for positive

screens

• Nurse does not screen patient—potential loss of screening knowledge and critical thinking

• Computer not reliably able to identify patients who have

infection • Computer not able to discern if

SIRS is valid or organ dysfunction is new

EMR—real time and scheduled

• Form fires and pre populates for nurse to screen upon admission and each shift—nurse critically thinks

• 24 hour screening • Manual screen completed when EMR

alert fires---nurse discerns/validates

appropriateness/correctness of alert

• Screening form needs to be developed in EMR—programing time and costs

SCREENING TOOL EXAMPLE

• Suspicion of / confirmed

infection?

• S/S infection?

• Any 1 organ

dysfunction?

= Severe Sepsis • Lactate > 4 mmol/L?

= Severe Sepsis with

hypoperfusion (30ml/kg

bolus) • SBP < 90 or MAP < 70 or SBP >

40 mmHg below baseline BP?

(30 ml/kg bolus)

• Hypotensive after bolus?

= Septic Shock

SCREENING TOOL EXAMPLE

SCREENING TOOL EXAMPLES

MAKE SCREENING FOR SEVERE SEPSIS PROCESS-DEPENDENT

• Weave into fabric of current practice

• Bedside nurse should do the screening

• Define expectation to screen during shift assessment and PRN with changes in patient’s conditions

• Screen for severe sepsis with every rapid response or medical response team call

• Identify strategies for initiation of therapy once patient with positive screen for severe sepsis is identified

ESTABLISH TRIGGER FOR RAPID IMPLEMENTATION OF SSC BUNDLES

• Clearly define next

steps for patients with

positive screen for

severe sepsis

– Alert RRT/Med Team

– Notify Physician

– Begin 3 hour bundle:

lactate, blood cultures, antibiotics, fluid

SBAR

Situation:

Screened Positive for Severe Sepsis

Background:

1. Positive Systemic Response to Infection

2. Known or suspected infection

3. Organ dysfunction: share which organs

Assessment:

Any other pertinent data or information to share

Recommendations:

1. I need you to come and evaluate the patient to

confirm if they have severe sepsis

2. It is recommended that I get an ABG, lactate, blood

cultures and a CBC (if > 12 hrs since last one). Can I

proceed and get these?

3. Any other labs you would like me to obtain? Do you

want to order antibiotics?

4. If patient is hypotensive: Can I start an IV and give a

bolus of NS—30ml/kg

Date/time of call: ________________

RRT called: Yes No

DEVELOP A PROTOCOL BASED ON THE SSC GUIDELINES

• Obtain lactate when have 2 SIRS and suspected

infection

• When screen positive for severe sepsis:

• Nurse protocol to draw labs and give fluid bolus

• Protocol done by RRT/Medical Response Team or all nurses

• Get medical staff approval

Severe Sepsis Algorithm

Screened Positive for Severe Sepsis

OTHER STRATEGIES TO FIND PATIENTS WITH SEVERE SEPSIS

Unit sepsis champions

Sepsis coordinator

ED and ICU rounding

RRT screen on every call

Prospective patient log

Part of nursing shift handoff

Discuss sepsis screen as part of Interdisciplinary Rounds

Reports

• Patients who screened positive

• Lactate

30

COMMON BARRIERS

• Providers not trusting the severe sepsis screen

– Steep learning curve

• Lack of education regarding the early signs and symptoms of

sepsis progression

– Screening is not sensitive only for severe sepsis

– Positive screen is not a diagnosis of severe sepsis

• Screening compliance

– Inconsistent screening process on the wards

– Improper evaluation of the screen

• False positives, false negatives

– Negative response from physician when notified of a

positive screen

STRATEGIES FOR BARRIER RESOLUTION

• Formal education regarding 3 and 6 hour bundles improves screening and compliance with EGDT – Physician and Nursing grand rounds

• Put education in nursing/physician orientation

– House staff lunch and learn

– Feedback on specific cases to providers, staff

– Physician champion • Reinforce education and process

• Perform audits to measure compliance and identify problems

• Round on unit and ask team how it is going and discuss issues

• Must assign responsibility and enforce accountability

• Sepsis team members report feedback to their disciplines

• Re-define the physician and nurses’ standard of care for sepsis

AUDIT SCREENING PROCESS

WHAT IS AN ‘AUDIT’

• An AUDIT

is a planned and documented activity performed

by qualified personnel to determine by

investigation, examination, or evaluation of

objective evidence, the adequacy and

compliance with established procedures, or

applicable documents, and the effectiveness of

implementation. [1]

1. "Audit defined in Six Sigma and Beyond: The Implementation

Process Volume VII, D.H. Stamatis (CRC Press, 2002)

WHAT DO WE WANT TO LEARN?

• Screening compliance = all of the patients are

being screened for severe sepsis

• Screens are valid = Are the screens being done

correctly

• Screens are reliable = Screens are consistent from

RN to RN

WHAT DO WE WANT TO COLLECT?

Screening compliance: Denominator: The total number of patients/charts eligible for inclusion

• e.g. the total number of patients on the unit

Numerator: The total number of patients/charts where the activity was completed

• e.g. the total number of patients on your unit for whom a sepsis screen was performed.

.

Recommend: upon admission, once per shift (within 2 hours of start of shift) and PRN

-

DEFINITIONS FOR SCREENING COMPLIANCE

• Denominator: The total number of patients/charts

eligible for inclusion

• e.g. the total number of patients on the unit

• Numerator: The total number of patients/charts

where the activity was completed

• e.g. the total number of patients on your unit for whom a

sepsis screen was performed.

DEFINITIONS FOR SCREENING VALIDITY

Correct screens: • TRUE POSITIVE: THE NUMBER OF PATIENTS WHO

SCREENED POSITIVE THAT WHEN VALIDATED TRULY

MET CRITERIA FOR SEVERE SEPSIS

• TRUE NEGATIVE: THE NUMBER OF PATIENTS WHO

SCREEN NEGATIVE THAT WHEN VALIDATED TRULY DID

NOT MEET CRITERIA FOR SEVERE SEPSIS

SEVERE SEPSIS SCREENING AUDIT TOOL Unit

Date Bed # Screened Yes No

Screen done correctly Yes No

Positive Screen for severe sepsis Yes No

Urgent Measures implemented appropriately

Yes No

Fluid bolus of 30ml/kg for patients with hypotension

Yes No N/A

Which labs were sent? Lactic acid, venous pH, CBC, blood culture

Were the General Care/Intermediate care bundle implemented?

Yes No N/A

If no, which elements were not completed

Vital signs, serial lactic acid, strict intake and output

Did patient with severe sepsis have a lactic acid >4mmol/L or septic shock (SBP<90 after 30ml/kg fluid bolus or requires vasopressors)

Yes No

If met above criteria, was the patient transferred to the appropriate level of care (ICU)

Yes No

Comments

39

EARLY IDENTIFICATION

• Timely identification of patients with severe sepsis

and septic shock is essential

• Components of the Surviving Sepsis bundles are all

time sensitive interventions:

• 3 Hour Bundle

• 6 Hour Bundle • Bundles should be applied to all patients with

severe sepsis and septic shock

• Will always be when the chart annotation suggests

signs and symptoms are all present.

• May be from nursing charting, lab flow sheets,

physician documentation, anything with a time

stamp.

• Will = triage time if all signs and symptoms are

present at triage.

41

SEP-1 Time Zero

• Severe Sepsis: 3 Hour and 6 Hour Counters

• Septic Shock: 3 Hour and 6 Hour Counters

• Clinical Example follows

42

SEP-1 Two Clocks

• A patient developed severe sepsis at 3:00 pm but

did not become hypotensive and fail to respond to

fluids until 5:00 pm, does the “shock clock” starts at

5 pm?

• If so, then does the physical exam requirement

“between hours 3-6” begin at 5 pm with the shock

clock or at 3 pm when severe sepsis was first noted?

43

SEP-1 Two Clocks

• The severe sepsis clock would start with the presentation of severe sepsis (3:00 pm) and the septic shock clock would start with presentation of septic shock (5:00 pm).

• The presentation of severe sepsis at 3:00 pm will trigger the

following counters with the start time being 3:00 pm:

"Sepsis Three Hour Counter" would require the following be completed by 6:00 pm: • Initial lactate level measurement • Antibiotic Administration • Blood Cultures prior to antibiotics

• "Sepsis Six Hour Counter" would require the following be completed by 9:00 pm: • Repeat lactate if initial lactate is > 2

44

SEP-1 Two Clocks

• The presentation of Septic Shock at 5:00 will trigger the following counters with the start time being at 5:00 pm:

• "Shock Three Hour Counter" would require the following be completed by 8:00 pm:

• Resuscitation with 30 mL/kg of crystalloid fluids

• "Shock Six Hour Counter" ONLY If hypotension persists would require the following be completed by 11:00 pm:

• Vasopressor administration

• Repeating the volume status and tissue perfusion assessment (item F)

45

SEP-1 Two Clocks

CASE EXAMPLES

CLINICAL SCENARIO 1: EARLY IDENTIFICATION AND INTERVENTION

• 88 year old, 51.6kg,white, female admit from ED;

resided in ECF

• History: CAD, COPD, dementia, Alzheimer

disease, depression, SVT

• Chief Complaint: rib pain, chest congestion and

SOB

• Awake, alert and oriented, slight combative

(history of combative behavior)

CLINICAL SCENARIO 1: EARLY IDENTIFICATION AND INTERVENTION

• Triage: Initial VS: (10 am)

• Temp: 101.6 F

• RR: 31

• HR: 109, atrial fib with occasional SVT

• B/P: 79/51

• 2L of O2, O2 sat of 96%

• Does this patient screen positive for severe sepsis?

Positive Screen for severe sepsis:

SIRS: HR >90; RR> 20; Temp > 38

Organ dysfunction: SBP<90mmHg

WHAT ARE THE NEXT STEPS?

Call physician—follow SBAR

Expected orders:

Give fluid bolus of 30ml/kg bolus

Labs drawn(lactate, CBC, ABG)

CLINICAL SCENARIO 1: EARLY IDENTIFICATION AND INTERVENTION

• Labs: • WBC: 11.5

• Hgb: 15.8

• Hct: 47.4

• BUN: 28 Creatinine:1.6

• Glucose:158

• BNP:78 (moderate CHF); troponin:0.03

• Lactic acid: 4.6

• U/A: positive for bacteria

• Blood cultures X 2 drawn

CLINICAL SCENARIO 1: EARLY IDENTIFICATION AND INTERVENTION

• CXR: RLL consolidation

• Additional Interventions:

• Broad spectrum antibiotics given STAT

• Lactic acid >4mmol/L so need a central line inserted and transfer to the ICU

• Fluid resuscitation continued until transfer

• Foley inserted

• Diagnosis: Septic Shock, Pneumonia , UTI, CHF

• Transferred to MICU

CLINICAL SCENARIO 2: EARLY IDENTIFICATION AND INTERVENTION

• 62 yr old male, 2 days post op s/p

colectomy, 73kg,receiving antibiotics

• Vital signs: 11am- HR 120. RR 24, BP 80/40,

temp: 102.2; urine output 100ml over last

4 hrs

• Screen patient for severe sepsis

Positive Screen for Severe Sepsis

SIRS: HR>90; RR>20; Temp> 100.4

Infection: on antibiotics

Organ dysfunction: BP 90

CLINICAL SCENERIO II (CONT)

What are your next steps?

SBAR:

•Call doctor, ask for ABG, lactate and CBC

and fluid bolus of 1800 cc of NS in one hour

•Doctor to come and evaluate the patient

One Hour later: 12pm

VS: BP 86/48, HR 132, RR 18, on 2L with sat 92%; lactate: 5.5

ABG: pH 7.08, pCO2-35, pO2-77; sat 92% with bicarb:10

What orders should you expect from the physician?

Because of both continued hypotension and increased

Lactate---this patient should be transferred to the ICU

TIER II: SCREENING FOR SEVERE SEPSIS MILESTONES AND CHECKLIST

• Develop screening process for ED, rapid response

team, ICU, and all floors (housewide)

• Develop audit process to evaluate compliance and

effectiveness

• Ensure screening process has clear “next steps”

defined for nursing staff

SEPSIS PROGRAM ACTION PLAN

Item Responsibility Due Date Status

1. Assemble team

2. Identify

executive

sponsor

3. Educate team

on evidence

4. Project

Charter

5. Baseline data

6. Define

screening tool

and process—for

ED, ICU, Floor, RRT

7. Define

screening audit

process 56

AGENDA ITEMS FOR FIRST COUPLE MEETINGS

• Out of meeting work for members: review SSC

guideline article and key research studies

• Educate team on sepsis and evidence based sepsis

management

• Begin work on Sepsis Project Charter

• Team composition---do we have all the right people

• Set up plan for baseline(or current state) data

collection

• Define, how charts will be identified, what data will be

collected, by whom and by when

• Define screening tool and process

• Define screening audit process 57

AGENDA ITEMS FOR FIRST COUPLE MEETINGS

• Out of meeting work for members: review SSC guideline

article and key research studies

• Educate team on sepsis and evidence based sepsis

management

• Review highlights from MHA Sepsis Collaborative—Jan and

Feb Calls

• Begin work on Sepsis Project Charter

• Team composition---do we have all the right people

• Set up plan for baseline(or current state) data collection

• Define, how charts will be identified, what data will be collected,

by whom and by when

• Draft timeline for implementation of each of the Tiers

• Develop screening process and screening audit process 58

STRATEGIES FOR KEEPING SEPSIS FRONT AND CENTER

• Align team with clinical and quality structures in

organization

• Sepsis program/goals part of hospital quality plan

• Reporting progress and data quarterly to executive

leadership

• Report to hospital board annually

• Standing agenda item on department meetings

• Communication plan---includes flyers, newsletters,

postings in units etc.

59

NEXT STEPS SEPSIS PROGRAM ACTION PLAN

Item Responsibility Due Date Status

1. Assemble team

2. Identify

executive

sponsor

3. Educate team

on evidence

4. Project

Charter

5. Baseline data

6. Define

screening tool

and process—for

ED, ICU, Floor, RRT

7. Define

screening audit

process 60

QUESTIONS?

© 2013 CHE Trinity Health 61

Questions:

Rhonda Dickman, MSN,

RN, CPHQ

Clinical Quality

Improvement Specialist

615-401-7404 - office

706-570-5700 - mobile

rdickman@tha.com

Angela Craig, APN, MS,

CCNS

ICU CCNS & Sepsis

Facilitator at CRMC

931-239-4904 - mobile

acraig@crmchealth.org